Palliative Care and Hospice: Opportunities to Improve Care for the Sickest Patients

The article discusses how palliative care and hospice services address the quality and cost concerns in the U.S. health care system. By focusing on symptom management, coordination among providers, and improved transitions of care, the services meet the needs of the sickest persons at lower costs. The author suggests putting in place the right leadership and resources and strengthening the workforce to successfully expand the programs

Palliative Care and the Health Care Crisis in the United States: A Candid Conversation With Dr. Diane Meier

This paper is a synthesis of the 2012 Lourie Lecture, framed as a series of questions and responses, and supported by images used in the lecture. I’m going to focus on the growth of this new field called palliative care and will make the connection that the crisis afflicting healthcare in the United States cannot be addressed without widespread scaling and implementation of palliative care across the system. My subject is not end-of-life care, but rather care during serious illness. A serious illness is something a person can live with for many years, such as emphysema, or end-stage renal disease on dialysis, or dementia. Of course, serious illnesses are also progressive and eventually lead to end-of-life, but I want to address care for a much broader patient population, not those who are clearly dying and who will qualify for hospice services

Developing a National Implementation Strategy to accelerate Uptake of Evidence-Based Family Caregiver Support in Us Cancer Centers

OBJECTIVE: Characterize key factors and training needs of U.S. cancer centers in implementing family caregiver support services. METHODS: Sequential explanatory mixed methods design consisting of: (1) a national survey of clinicians and administrators from Commission-on-Cancer-accredited cancer centers (N = 238) on factors and training needed for establishing new caregiver programs and (2) qualitative interviews with a subsample of survey respondents (N = 30) to elicit feedback on survey findings and the outline of an implementation strategy to facilitate implementation of evidence-based family caregiver support (the Caregiver Support Accelerator). Survey data was tabulated using descriptive statistics and transcribed interviews were analyzed using thematic analysis. RESULTS: top factors for developing new caregiver programs were that the program be: consistent with the cancer center\u27s mission and strategic plan (87%), supported by clinic leadership (86.5%) and providers and staff (85.7%), and low cost or cost effective (84.9%). top training needs were how to: train staff to implement programs (72.3%), obtain program materials (63.0%), and evaluate program outcomes (62.6%). Only 3.8% reported that no training was needed. Qualitative interviews yielded four main themes: (1) gaining leadership, clinician, and staff buy-in and support is essential; (2) cost and clinician burden are major factors to program implementation; (3) training should help with adapting and marketing programs to local context and culture; and (4) the Accelerator strategy is comprehensive and would benefit from key organizational partnerships and policy standards. CONCLUSION: Findings will be used to inform and refine the Accelerator implementation strategy to facilitate the adoption and growth of evidence-based cancer caregiver support in U.S. cancer centers

Availability of Family Caregiver Programs in Us Cancer Centers

IMPORTANCE: Family caregivers provide the majority of health care to the 18 million patients with cancer in the US. Yet despite providing complex medical and nursing care, a large proportion of caregivers report no formal support or training. In recognition of this gap, many interventions to support cancer caregivers have been developed and tested over the past 2 decades. However, there are few system-level data on whether US cancer centers have adopted and implemented these interventions. OBJECTIVE: to describe and characterize the availability of family caregiver support programs in US cancer centers. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional national survey study was conducted between September 1, 2021, and April 30, 2023. Participants comprised clinical and administrative staff of Commission on Cancer-accredited US cancer centers. Data analysis was performed in May and June 2023. MAIN OUTCOMES AND MEASURES: Survey questions about the availability of 11 types of family caregiver programs (eg, peer mentoring, education classes, and psychosocial programs) were developed after literature review, assessment of similar program evaluation surveys, and discussions among a 13-member national expert advisory committee. Family caregiver programs were defined as structured, planned, and coordinated groups of activities and procedures aimed at specifically supporting family caregivers as part of usual care. Survey responses were tabulated using standard descriptive statistics, including means, proportions, and frequencies. RESULTS: Of the surveys sent to potential respondents at 971 adult cancer centers, 238 were completed (response rate, 24.5%). After nonresponse weight adjustment, most cancer centers (75.4%) had at least 1 family caregiver program; 24.6% had none. The most common program type was information and referral services (53.6%). Cancer centers with no programs were more likely to have smaller annual outpatient volumes (χ2 = 11.10; P = .011). Few centers had caregiver programs on training in medical and/or nursing tasks (21.7%), caregiver self-care (20.2%), caregiver-specific distress screening (19.3%), peer mentoring (18.9%), and children caregiving for parents (8.3%). Very few programs were developed from published evidence in a journal (8.1%). The top reason why cancer centers selected their programs was community members requesting the program (26.3%); only 12.3% of centers selected their programs based on scientific evidence. Most programs were funded by the cancer center or hospital (58.6%) or by philanthropy (42.4%). CONCLUSIONS AND RELEVANCE: In this survey study, most cancer centers had family caregiver programs; however, a quarter had none. Furthermore, the scope of programming was limited and rarely evidence based, with few centers offering caregiving education and training. These findings suggest that implementation strategies are critically needed to foster uptake of evidence-based caregiver interventions

Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel

Despite increasing interest in advance care planning (ACP) and prior ACP descriptions, a consensus definition does not yet exist to guide clinical, research, and policy initiatives

Dense Gas, Dynamical Equilibrium Pressure, and Star Formation in Nearby Star-Forming Galaxies

We use new ALMA observations to investigate the connection between dense gas fraction, star formation rate, and local environment across the inner region of four local galaxies showing a wide range of molecular gas depletion times. We map HCN (1-0), HCO$^+$ (1-0), CS (2-1), $^{13}$CO (1-0), and C$^{18}$O (1-0) across the inner few kpc of each target. We combine these data with short spacing information from the IRAM large program EMPIRE, archival CO maps, tracers of stellar structure and recent star formation, and recent HCN surveys by Bigiel et al. and Usero et al. We test the degree to which changes in the dense gas fraction drive changes in the SFR. $I_{HCN}/I_{CO}$ (tracing the dense gas fraction) correlates strongly with $I_{CO}$ (tracing molecular gas surface density), stellar surface density, and dynamical equilibrium pressure, $P_{DE}$. Therefore, $I_{HCN}/I_{CO}$ becomes very low and HCN becomes very faint at large galactocentric radii, where ratios as low as $I_{HCN}/I_{CO} \sim 0.01$ become common. The apparent ability of dense gas to form stars, $\Sigma_{SFR}/\Sigma_{dense}$ (where $\Sigma_{dense}$ is traced by the HCN intensity and the star formation rate is traced by a combination of H$\alpha$ and 24$\mu$m emission), also depends on environment. $\Sigma_{SFR}/\Sigma_{dense}$ decreases in regions of high gas surface density, high stellar surface density, and high $P_{DE}$. Statistically, these correlations between environment and both $\Sigma_{SFR}/\Sigma_{dense}$ and $I_{HCN}/I_{CO}$ are stronger than that between apparent dense gas fraction ($I_{HCN}/I_{CO}$) and the apparent molecular gas star formation efficiency $\Sigma_{SFR}/\Sigma_{mol}$. We show that these results are not specific to HCN.Comment: 31 pages, 13 figures, accepted for publication in The Astrophysical Journal, email for access to data table before publicatio

Palliative care early in the care continuum among patients with serious respiratory illness an official ATS/AAHPM/HPNA/SWHPN policy statement

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary–critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary–critical care clinicians and policymakers for its proactive integration

Do Spectroscopic Dense Gas Fractions Track Molecular Cloud Surface Densities?

We use ALMA and IRAM 30-m telescope data to investigate the relationship between the spectroscopically-traced dense gas fraction and the cloud-scale (120 pc) molecular gas surface density in five nearby, star-forming galaxies. We estimate the dense gas mass fraction at 650 pc and 2800 pc scales using the ratio of HCN (1-0) to CO (1-0) emission. We then use high resolution (120 pc) CO (2-1) maps to calculate the mass-weighted average molecular gas surface density within 650 pc or 2770 pc beam where the dense gas fraction is estimated. On average, the dense gas fraction correlates with the mass-weighted average molecular gas surface density. Thus, parts of a galaxy with higher mean cloud-scale gas surface density also appear to have a larger fraction of dense gas. The normalization and slope of the correlation do vary from galaxy to galaxy and with the size of the regions studied. This correlation is consistent with a scenario where the large-scale environment sets the gas volume density distribution, and this distribution manifests in both the cloud-scale surface density and the dense gas mass fraction.Comment: 11 pages, 4 figures, accepted for publication in The Astrophysical Journal Letter

How empowering is hospital care for older people with advanced disease? Barriers and facilitators from a cross-national ethnography in England, Ireland and the USA

Erworben im Rahmen der Schweizer Nationallizenzen (http://www.nationallizenzen.ch)Background: Patient empowerment, through which patients become self-determining agents with some control over their health and healthcare, is a common theme across health policies globally. Most care for older people is in the acute setting, but there is little evidence to inform the delivery of empowering hospital care. Objective: We aimed to explore challenges to and facilitators of empowerment among older people with advanced disease in hospital, and the impact of palliative care. Methods: We conducted an ethnography in six hospitals in England, Ireland and the USA. The ethnography involved: interviews with patients aged ≥65, informal caregivers, specialist palliative care (SPC) staff and other clinicians who cared for older adults with advanced disease, and fieldwork. Data were analysed using directed thematic analysis. Results: Analysis of 91 interviews and 340 h of observational data revealed substantial challenges to empowerment: poor communication and information provision, combined with routinised and fragmented inpatient care, restricted patients’ self-efficacy, self-management, choice and decision-making. Information and knowledge were often necessary for empowerment, but not sufficient: empowerment depended on patient-centredness being enacted at an organisational and staff level. SPC facilitated empowerment by prioritising patient-centred care, tailored communication and information provision, and the support of other clinicians. Conclusions: Empowering older people in the acute setting requires changes throughout the health system. Facilitators of empowerment include excellent staff-patient communication, patient-centred, relational care, an organisational focus on patient experience rather than throughput, and appropriate access to SPC. Findings have relevance for many high- and middle-income countries with a growing population of older patients with advanced disease